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To the Editor.—
The commentary by Florin et al1 highlights some of the relevant issues for clinical recognition, treatment, environmental evaluation, and developmental follow-up for children in whom elevated whole-blood lead levels are detected. Lead-screening programs are a needed part of well-child assessments, but massive lead poisoning rarely has an unusual presentation. Unfortunately, these authors did not cite our complete case report2 but rather focused on a brief Morbidity and Mortality Weekly Report article3 (copublished in the Journal of the American Medical Association) regarding the 4-year-old boy who swallowed a metallic medallion from a necklace purchased from a gum-ball vending machine in Redmond, Oregon. The medallion was retrieved by endoscopy (along with a quarter) 
3 to 4 weeks after the mother recollected its purchase. His whole-blood lead level was 123 µg/dL, and normocytic anemia with basophilic stippling of the erythrocytes was documented. Treatment with dimercaprol followed by calcium disodium versenate and multiple courses of succimer over the next 22 months resulted in whole-blood lead levels of 20 to 30 µg/dL. Although Florin et al suggest that "chronic" rather than "acute" lead intoxication was likely responsible for the child's lead poisoning, the time course is entirely consistent with the documented elevation in zinc protoporphyrin to 556 µmol/dL 3 weeks after initial hospitalization (5–6 weeks from the likely time of ingestion). These commentators speculate that chronic lead exposure was missed by incomplete environmental surveillance. A careful analysis of the child's home (built in 1996), play areas, surrounding soils, and household items (including glass and pottery) failed to detect another source of lead. Neither parent had occupations in which lead was used (they both had whole-blood lead levels of <3 g/dL), and a sibling who is 2 years older had a whole-blood lead level of 5 µg/dL. Analysis of the medallion and others retrieved from several vending machines throughout Oregon found lead levels of 399000 ppm (39.9% by weight).
Neurologic examinations, electroencephalograms, and brain-imaging studies failed to reveal abnormalities during the initial hospitalization or later. Developmental examinations have remained "normal" for age over the last 22 months, and testing for higher function and problem-solving skills will continue, augmented by ongoing educational evaluations of cognitively development. Although encouraging to date, long-term developmental assessment planning has been arranged for this child.
To what degree it is sufficient to lower the whole-blood lead level was addressed by the American Academy of Pediatrics' "Treatment Guidelines for Lead Poisoning in Children"4 and ongoing discussions with the Oregon Poison Control Center and others. This guideline advises that "patient's with blood levels of 25–35 µg/dL need aggressive environment intervention but should not routinely receive chelation therapy, because no evidence exists that chelation avoids or reverses neurotoxicity." Furthermore, neither succimer or D penicillamine is currently labeled for treatment of whole-blood lead levels of <45 µg/dL, although some courses of succimer were used in this patient when levels rebounded to >35 µg/dL.
The Oregon health agencies' response to this ingestion included an immediate public health alert and immediate notification of the vendors within Oregon, notification of the Centers for Disease Control and Prevention, and the Consumer Product Safety Commission through our congressional delegation. Our reports form the basis for the recall of 150 million pieces of jewelry with unsuspected high lead contents (the largest product recall in US history) because analysis of these toy necklaces and other jewelry pieces (imported primarily from India) found high levels of lead. Recently, the Consumer Product Safety Commission issued regulations that limit the amount of lead in jewelry or toys to <600 ppm.5 Health Canada is also attempting to protect Canadian children by proposing regulations, because a similar ingestion was documented in a 5-year-old in Ottawa, Ontario, who simply pursed her lips around a similar necklace medallion and mouthed it.6,7
Although we agree that continued vigilance for unsuspected sources of lead for possible ingestion is a task for all pediatricians and should remain a high federal priority, we believe that our identification of this instance of "acute" lead poisoning, our environmental evaluation, clinical treatment, and ongoing neurodevelopmental evaluations constituted an appropriate response. We are hopeful that our advocacy averted other children from potential toxic exposures and that a single case report from rural Oregon can make a difference nationally.
Continued monitoring of our index child's whole-blood lead levels currently shows a lead level of 22 µg/dL, and monitoring of neurodevelopmental performance in ongoing.
REFERENCES
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